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MANAGEMENTOF

SEVERE MALNUTRITION

MARNIAR

C20911804

MANAGEMENT OF SEVERE MALNUTRITION:A MANUAL FOR PHYSICIANS AND OTHER

SENIOR HEALTH WORKERSWorld Health Organization

Geneva, 1999

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INITIAL PHASE

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PRINCIPLES OF MANAGEMENT

Children with severe malnutrition are often seriously ill when they first present for treatment

should be kept in a special area

constantly monitored

25–30 °C

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Initial treatment begins with admission to hospital and lasts until the child’s condition is stable and

his or her appetite has returned

2–7 days

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The principal tasks during initial treatment are :

to treat or prevent hypoglycaemia and hypothermia

to treat or prevent dehydration and restore electrolyte balance

to treat incipient or developed septic shock, if present

to start to feed the child

to treat infection

to identify and treat any other problems, including vitamin deficiency, severe anaemia and heart failure

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HYPOGLYCAEMIAAll severely malnourished children are at risk of developing HYPOGLYCAEMIA

serious systemic infection

has not been fed for 4–6 hours

THE CHILD SHOULD BE FED

AT LEAST EVERY 2 OR 3 HOURS

DAY AND NIGHT

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Signs of hypoglycaemia

low body temperature (<36.5 °C) lethargy

limpnessloss of consciousness

OFTEN, THE ONLY SIGN BEFORE DEATH IS DROWSINESS

If hypoglycaemia is suspected, treatment should be given

immediately without laboratoryconfirmation

If the patient is conscious or can be roused and is able to drink, give 50 ml of 10%

glucose or sucrose, or give F-75 diet by mouth

If the child is losing consciousness, cannot be aroused or has convulsions, give 5 ml/kg of body weight of sterile 10% glucose intravenously (IV),

followed by 50 ml of 10% glucose or sucrose by nasogastric (NG) tube

All malnourish

ed children with su

spected

hypoglycaemia should also

be treated

with broad-sp

ectrum antimicrobials f

or

serious syste

mic infection

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HYPOTHERMIA

Infants under 12 months, and those with marasmus, large areas of damaged skin or serious infections are

highly susceptible to hypothermia

the rectal temperature < 35.5 °C or

the underarm temperature < 35.0 °C

kangaroo technique

clothe the child well (including the head), cover with a warmed blanket and place an

incandescent lamp over

The rectal temperature must be measured every 30 minutes during rewarming with

a lamp

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DEHYDRATION AND SEPTIC SHOCK

Dehydration and septic shock are difficult to differentiate in a child

with severe malnutrition

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Comparison of clinical signs of dehydration and septic shock in the severely

malnourished child

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Treatment of dehydrationWhenever possible, should be

rehydrated orally

Because severely malnourished children are deficient in potassium and have abnormally high levels of sodium, the oral rehydration

salts (ORS) solution should contain less sodium and more potassium

Magnesium, zinc and copper

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Amount of ReSoMal to give

70 -100 ml / kg is usually enough to restorenormal hydration

5 ml/kg every 30 min. The 1st 2 h, orally/NGT

5 – 10 ml/kg/h

12 h

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ReSoMal should be stopped if:

the respiratory and pulse rates increase

the jugular veins become engorged

there is increasing oedemaSIGNS OF

OVERHYDRATION

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Rehydration is completed when :

the child is no longer thirsty

urine is passed

Any other signs of dehydration have disappeared

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Fluids given to maintain hydration should be based on :

the child’s willingness to drink

the amount of ongoing losses in the stool

< 2 y : 50–100 ml

older : 100–200 mlafter each loose stool until diarrhoea stops

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How to give ReSoMal ?

oral

NGT

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Intravenous rehydration

circulatory collapse caused by severe dehydration or septic shock

•Ringer’s lactate solution with 5% glucose• 0.45% (half-normal) saline with

5% glucose

15 ml/kg 1 h

!!! Overhydration

NGT 10 ml/kg/h

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Feeding during rehydration

breastfeeding should not be interrupted

give the F-75 diet as soon as possible

Oral/NGT

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Treatment of septic shockseverely

malnourishedseptic shock

• signs of dehydration, but without a history of watery diarrhoea

• hypothermia or hypoglycaemia• oedema and signs of dehydration

•should immediately be given broad-spectrum antibiotics•be kept warm to prevent or treat hypothermia•should not be handled any more than is essential for treatment

IVFD 15 ml/kg/h Observe every 5-10min.

the radial pulse becomes strong /conscious

orally or by NGT

Sign of CHF (+) / not improve after 1 h

Blood transfusion 10 ml/kg, 3 h

F-75 diet by NGT

abdominal distension or vomits repeatedly

give the diet more slowly

not resolve

stop feeding and IVFD 2–4 ml/kg/h + 2 ml of 50% magnesium sulfate solution IM

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Formula diets for severely malnourished children

F-75 Initial phase

rehabilitation phaseF-100

80 – 100kcal/kg/d

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NGT

• very poor appetite•weakness • painful stomatitis

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Vitamin A deficiency

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Other vitamin deficiencies

• all malnourished children should receive 5 mg of folic acid orally on day 1 and then 1mg orally per day thereafter

• deficient in riboflavin, ascorbic acid, pyridoxine, thiamine and the fat-soluble vitamins D, E and K

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Very severe anaemia

Hb< 40 g/l Very severe anaemia

HEART FAILURE

10 ml/kg of packed red cells or whole blood slowly over 3 hours

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REHABILITATION PHASE

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:

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Principles of management• to encourage the child to eat as much as

possible• to re-initiate and/or encourage

breastfeeding as necessary• to stimulate emotional and physical

development• to prepare the mother or carer to

continue to look after the child after discharge

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F-100 150 - 220 kcal/kg/d, every 4 h

Transition to the rehabilitation phase involves increasing the amount of diet given

at each feed by 10 ml

F-100 should be continued until the child achieves -1 SD (90%) of the median NCHS/ WHO reference values for weight-for-height

Folic acid 5 mg on day 1st and than1 mg/d thereafter

Iron 3 mg/kg/d, 2 doses, max.60 mg/d for 3 mo

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Assessing progress

-1 SD (90%) of the median NCHS/WHO reference values for weight-for-height

weight gain : 10–15 g/kg/d

2–4 weeks

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MALNUTRITION IN ADOLESCENTS

AND ADULTS

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Criteria for discharge

Adults :BMI is >18.5

Adolescents : BMI-for-age >5th percentile of the median

NCHS/WHO reference values

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• Initial treatment: life-threatening problems are identified and treated, specific deficiencies are corrected, metabolic abnormalities are reversed and feeding is begun.

• Rehabilitation: intensive feeding is given to recover most of the lost weight, emotional and physical stimulation are increased, the mother or carer is trained to continue care at home, and preparations are made for discharge of the child.

• Follow-up: after discharge, the child and the child’s family are followed to prevent relapse and assure the continued physical, mental and emotional development of the child.

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Thank you